Employee Sick Leave Acknowledgement Form

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EMPLOYEE
SICK LEAVE ACKNOWLEDGEMENT FORM
(AB 1522)
In addition to illness, employees may use accrued sick leave under the following circumstances:
diagnosis, care, treatment of existing health condition or preventative care for the student or a family
member*; or when the employee is a victim of domestic violence, sexual assault or stalking. All
requests will be in writing. However, in an emergency situation, the employee is expected to contact
the supervisor by phone, text or email to make the request.
Whenever possible, the employee shall provide advance notification to the supervisor at least three
(3) working days prior to the intended absence. Notification may be in person, by phone, text or
email. If the need for the use of sick leave is unforeseeable, the employee shall provide notice to the
supervisor as soon as practicable.
I have read and understand the above.
____________________________________
Employee Signature
Employee Name: _________________________________________
Print Name
Date: ___________________
*
Family member is defined as a child (biological, adopted, foster, step, legal ward; biological, adoptive or foster parent, stepparent, or
legal guardian of the individual or individual’s spouse or registered domestic partner; spouse; registered domestic partner; grandparent;
grandchild; sibling.
EMPLOYEE
SICK LEAVE ACKNOWLEDGEMENT FORM
(AB 1522)
In addition to illness, employees may use accrued sick leave under the following circumstances:
diagnosis, care, treatment of existing health condition or preventative care for the student or a family
member*; or when the employee is a victim of domestic violence, sexual assault or stalking. All
requests will be in writing. However, in an emergency situation, the employee is expected to contact
the supervisor by phone, text or email to make the request.
Whenever possible, the employee shall provide advance notification to the supervisor at least three
(3) working days prior to the intended absence. Notification may be in person, by phone, text or
email. If the need for the use of sick leave is unforeseeable, the employee shall provide notice to the
supervisor as soon as practicable.
I have read and understand the above.
____________________________________
Employee Signature
Employee Name: _________________________________________
Print Name
Date: ___________________
*
Family member is defined as a child (biological, adopted, foster, step, legal ward; biological, adoptive or foster parent, stepparent, or
legal guardian of the individual or individual’s spouse or registered domestic partner; spouse; registered domestic partner; grandparent;
grandchild; sibling.

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